I initiated regular coverage of the biotech industry at Forbes, and wrote many of the early stories on genomics, personalized medicine, and the automation of drug making. I also launched the Arabic edition of Forbes, and oversaw what became highly influential lists in the Middle East, such as the 50 Most Powerful Arab Businesswomen. Qaddafi's daughter really wanted to be on it, and George Bush mentioned the list at the World Economic Forum. In between, I helped my father, a nephrologist, form a start-up that develops software to assist general practitioners in diagnosing patients. It is part of the exciting new field of health information technology, and it is going to shape the way we interact with our doctors.
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Concierge Medicine For The Poorest

The number of doctors enrolled in Medicare last year has hardly changed since 2005, and participants have increased less than 5%. Doctors have recently averted a 27% cut in Medicare payments, but that will only last until the end of the year. There are simply no financial incentives for them to care for the sickest people.

Not for the Chens, a family of doctors from Miami, Florida. Where others avoid patients on Medicare, they have spotted an opportunity. James Chen, and his son Christopher run Chen Medical Centers, a chain of eight clinics in the Miami area, employing more than 40 primary care doctors, including 25 specialists. Other family members include son Gordon, a cardiologist and Tiger Mom Mary (as Chris Chen calls her) who’s the chief operating officer. Last year, the Chens opened two clinics in Richmond, Virginia, and three in Norfolk. Five more will open in both cities this summer. “Virginia is highly underserved for Medicare,” says Chris Chen, also a cardiologist, and the group’s chief executive officer. He’s searching for other markets, primarily in the Southeast. To fund the expansion, ChenMed has raised money from angel and corporate investors, but Chen declines to give details.

As early as 1985, James Chen, a 63-year-old internist, started focusing on sicker, older, and poorer patients (less than 5% can afford a supplemental plan). As a preventive measure, he saw them every month, whereas doctors typically see Medicare patients every four to six months. “He gained a reputation for liking sick people,” says Chris Chen. However, it wasn’t until 2003, when Chen became a patient himself that he realized how inefficient the health care system can be. Doctors had grossly misdiagnosed him, telling Chen he had a cancerous mass at the base of his brain stem. They informed him that he had six months to live, but would need radical surgery to cut the area around his eyes, nose, and part of his mouth.

Luckily, Chen had a treatable form of lymphoma, and has recovered. During his ordeal, he was struck by the doctors’ lack of compassion, their lack of accountability—they got paid regardless of outcome, the absence of coordination between specialists, and the length of time it took to book appointments. He no longer practices, but has applied those lessons to build ChenMed.

1- Doctors see patients every month, but daily slots are available in case of an urgent appointment. They’re able to do so, by limiting the total ratio of patients to doctors. It is 375 to 1; as opposed to the typical 1,200-2,000 to 1.

2- Specialists are available at the clinics, so that an 85-year-old doesn’t have to travel to different locations.

3- The sickest and poorest patients don’t have the means to travel, so the Chens provide a chauffeured van for door-to-door transportation. There’s also a pharmacy at the clinics.

4- Doctors are held accountable. If a patient has a bad outcome, the doctor has to explain the case to the rest of the group. Patient cases are discussed three times a week. Doctors get a bonus if they improve outcome. (They don’t get equity).

ChenMed bears the full risk of managing Medicare payments for hospital stays, doctors, and medications, but Chris Chen says its strategy of focusing on preventive measures, instead of rationing health care is paying off, and ChenMed is profitable. Hospital admission rates for Chen patients (per 1,000 patients) are 18% less than the national rate, and 17% less for readmissions. Cholesterol levels for Chen patients taking statin drugs are 22% lower than the national average.

Technology also plays an important role. ChenMed employs 15 software developers who create everything in-house, including electronic health records. When doctors meet three times a week, they discuss, among other things, ways to improve care. They then relay their ideas to the IT folks. One example is the “Life Card,” which is the size of a credit card. Instead of filling out paperwork at every visit, and handing out insurance information, patients just scan their card, which also informs them of their estimated wait time. Their EKG is burned on the back of the card, and can be seen with the naked eye, in case the patient is admitted to a hospital.

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This is extraordinary — outcomes similar to Kaiser, Group Health, and Geisinger for the poorest and most vulnerable Medicare patients at a fraction of the costs. Even more surprising that this model emerged in Miami who consistently duke it out with McAllen and other high utilization markets for the highest per capita costs.

Nice to see how changing the payment model — can change the delivery model creating value for patients, Medicare, and providers.

There are companies like ChenMed popping up all over the place, though few as interested in the medicare and medicaid population as the Drs. Chen, nor as good at managing the low income “hotspotters” as Dr. Atul Gawande called them. Other examples include One Medical, Qliance, CarePractice, ExclusiveMD, and about 200 more that are listed on the website we set up for such practices almost two years ago. We have helped thousands locate great care for reasonable fees and are always glad to help more. See FairCareMD.com if you are interested.

While this is a good start, there is a great deal more of this coming. Tens of thousands of physicians have signed up to be part of “Accountable Care Organizations”, or ACOs which require physicians to behave like the Chens. In ACOs the physicians are rewarded for making patients healthier based upon standardized metrics. This is just one of many complex, yet potentially helpful aspects of the Affordable Care Act, one that looks like it may work.

Great Article Zina, thanks for reporting on the good news in healthcare. There is indeed hope for our troubled system.

Yes, but the Chens are making it work, something we can all learn from. Actually I have seen many new low cost concierge practices struggle to find their model and am happy to report that the majority have been fabulously successful, fulfilling a largely unmet need that patients respond well to.

I would go as far to say that there is far more risk in the traditional 7 minute medicine model where an overworked practitioner with too little time and limited diagnostic data tries to treat and diagnose patients accurately. I have been in this scenario as a patient advocate and seen my loved ones almost die because of the mistakes made by physicians that fail to adequately understand the patient prior to decision making. The problems compound in these scenarios as the providers and institutions then go into legal-medicine mode in favor of logical choices for care. In contrast, studies show that doctors like the Chens are sued far less frequently than average, largely because they are so involved with the patients and obviously care.

As we implement ACOs around the country it behooves all of us to expect our physicians to act like the Chens. With government incentives to do so and the fact that it just feels better to practice this way, this can be our future if we demand it.

I think Dr Aaron Carroll summarized the evidence best in an article on KevinMD last year. He cites a number of well done studies. Essentially the message is that on average, nice guys finish first when it comes to malpractice. While it is hard to do a great quantitative study on bad bed side manners, it would appear that a good physician/ patient relationship is the most accurate predictor of litigation outcomes. Does this describe the Chens? It sounds like it.

I should say i admire Dr. Chen and his team. Things are different here in New York. In my practice, I see up to 30 patients a day, but I reserve special time slots for my “concierge” patients. I don’t have too many of them, but still I have a special waiting room and different policies. I answer calls after-hours and just go extra mile to make them happy.

As per pricing, that’s indeed not cheap. Some of the businesses mentioned by Alex only charge for things that are normally provided by other physicians regardless, others are simply a legal marketing proxy for the companies to work with the doctors.